COVID-19 Pandemic

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Salient Points

This article focuses on the following:

  • Clinical management,
  • Procedure of sample collection from COVID-19 patients,
  • Infection control and prevention protocol in case of COVID-19 pandemic.

It also discusses the in-house production of hand sanitizers, full PPE kit and the importance of assessing mental health (stress and anxiety), this includes doctors, children, older adults and individuals in isolation. The article also highlights the identified areas of care for COVID-19 patients, tele-consultation guidelines for SJMCH doctors, workflow of embalming and standard precautions to be followed by healthcare workers when handling the bodies of dead COVID-19 victims.

Detailed Summary

  • Hydroxychloroquine

Oral: Hydroxychloroquine – 200 mg TID for 10 days.

Azithromycin 500mg OD for 5 days, combination can be considered to enhance viral clearance. Note – Combination therapy may predispose to QT prolongation – needs close ECG monitoring.

Serious adverse effects may include:

  1. QT prolongation and Torsades de Pointes
  2. Reduction in seizure threshold
  3. Anaphylaxis
  4. Neuromuscular impairment
  5. Neuropsychiatric disorders (potential to increase delirium)
  6. Pancytopenia, neutropenia, thrombocytopenia, aplastic anaemia
  7. Hepatitis

Note – HCQ May require dose adjustment in renal or hepatic dysfunction.

  • Alternative regimen for Severe nCOV– Lopinavir/Ritonavir combination therapy

Indications:

  1. Respiratory distress with respiratory rate >= 22bpm or SpO2 of < 94%
  2. Lung parenchymal infiltrates on chest X-ray
  3. Hypotension defined as SBP <90 mmHg or need for vasopressor/inotropic medication
  4. New-onset organ dysfunction:
    1. Increase in creatinine by 50% from baseline, glomerular filtration rate (GFR) reduction by >25% from baseline or urine output of <0.5 ml/kg for six hours,
    2. Reduction of GCS score by two or more
    3. Any other organ dysfunction.
  5. High-risk groups:
    1. Age >60 year
    2. Diabetes mellitus
    3. Renal failure
    4. Chronic lung disease
    5. Immunocompromised persons.

Dosage of Lopinavir/Ritonavir

  • Lopinavir – 200mg
  • Ritonavir – 50mg

Oral Regime – 2 tablets every 12 hr for 14 days or 7 days after becoming asymptomatic (whichever is earlier)

Nasogastric tube – 400mg lopinavir/100mg ritonavir every 12 hr for 14 days or 7 days after becoming asymptomatic (whichever is earlier)

  • Respi ER protocol
  • Incubation Protocol for suspected COVID-19 cases
  1. Personnel
  2. Equipment
  3. Decision Making
  4. Donning PPE
  5. Preparation Phase
  6. Pre-oxygenation
  7. Pre-medication
  8. Paralysis and Sedation
  9. Patient Positioning
  10. Placement of Tube
  • Anaesthetic management of Suspected/Confirmed COVID-19 patients.
  1. Preparation
  2. Machine preparation
  3. Anaesthetic technique
  • Anaesthetic Management of Suspected/Confirmed COVID-19 patients.
  1. General anesthesia
  2. Pre-oxygenation
  3. Induction
  4. Extubation
  • SOP for COVID-19 in ICU
  1. Admission criteria
  2. Workflow plan for 1st and 2nd suspected or proven case
  3. PPE
  4. Communication protocol
  5. Medical management protocol
  6. Disinfection and specimen shipment protocol
  7. Dead Body management
  8. Special instructions to HCPs
  • Discharge Criteria for screening patients with suspected COVID-19
  • Corona Prophylaxis for HCPs
  • Procedure for COVID-19 Sample collection
    ⁕ After wearing full PPE,
    ⁕  Label both the tubes with patient details and the name of the hospital
    ⁕  Use 1 swab to swab the posterior pharyngeal wall. Place it into the smaller tube containing Viral Transport Medium (VTM). Break off the end of the swab at the indentation.
    ⁕  Use the 2nd swab to swab both nostrils and place it into the same tube which contains VTM. Close the tube.
    ⁕  Place this VTM tube into the bigger tube. Close this tube.
    ⁕  Place the bigger tube into a ziplock cover.
    ⁕  Discard full PPE into appropriate BMW liners.
    ⁕  The aide should wear gloves and a mask and immediately (as a cold chain has to be maintained once a sample is collected) transport to the Microbiology laboratory – holding the sample ziplock cover in one hand and request forms ziplock cover in the other.
  • Hospital Isolation/Quarantine Instructions
  • Standard Contact and Droplet Precautions

Standard, contact, and droplet precautions

  • Perform hand hygiene before and after every patient contact.
  • Safe disposal or cleaning of instruments and linen.
  • Private room preferred.
  • Gloves required upon entering the room.
  • Change gloves after contact with contaminate secretions.
  • Gown required if clothing may come in contact with the patient or environmental surfaces or if the patient has diarrhea.
  • Mask: Wear a mask (surgical) when within 3 feet of the patient. Mask (surgical) the patient during transport.
  • Minimize risk of environmental contamination during patient transport (eg, patients can be placed in a gown).
  • Non-critical items should be dedicated to use for a single patient if possible.

Cough etiquette: Patients and visitors should cover their nose or mouth when coughing, promptly dispose of used tissues, and practice hand hygiene after contact with respiratory secretions.

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